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- ↵*Reprint requests and correspondence: Dr. Arthur Garson, Jr., Baylor College of Medicine, MC-14460, 6621 Fannin Street, Houston, Texas 77030
The century’s end has inspired many of us to try our hand as futurists. This year, marking the end of the century and the beginning of the College’s second half-century, has provided the American College of Cardiology (ACC) with numerous opportunities to look at what the College has done so far and to analyze how the challenges of the next half-century should be approached.
In December 1999, the College’s past presidents, officers, trustees, and governors gathered with renowned futurists in New York City to conduct a Forum on the Future, an opportunity to examine the delivery of quality cardiovascular care in the twenty-first century. Next month, JACCwill feature the results of the forum, a consensus document on cost, technology, demographics, and the College’s response to changes in these areas. To set the stage for the publication of this important document, I offer for consideration my thoughts on the future, which were published as an Afterword in the ACC commemorative book, American College of Cardiology: A Visual History, 1949–1999 (1):
“Although predicting is perilous, not predicting is even more perilous. It leaves us unprepared for the changes going on right under our noses, confronts us with recurrent surprises and makes us reactors instead of agents of change.” —Jerome Kassirer
Predicting the next hundred years is relatively simple; predicting the next 10 is very difficult. In 1980, I was asked to predict the next 10 years of our field and then was held accountable in 1990 when I was asked to give a talk (called “Back to the Future: Part II”) summarizing the success of my predictions. My range finding was off: two of the predictions have only begun to occur 18 years later. Undaunted as to prediction, I do believe there will be changes in three important areas in the next millennium: in our practice, in our physicians, and in our health care.
Our practice will become more focused on prevention. The prevention of coronary artery disease and stroke by manipulation of molecular and mechanical factors is likely to precede the prevention of cardiomyopathies, heart failure, and congenital heart disease. Molecular diagnosis will precede molecular treatment; nonetheless, conventional treatments will be more productive, with earlier warning provided by molecular diagnosis.
Long before these more global advances, incremental advances will move toward noninvasive assessment of the coronary circulation, minimally invasive approaches to coronary artery diseases, and application of molecular techniques to enable focused regeneration of myocardium and specialized conducting tissue.
Transplantation immunology and ethics will need to advance significantly to address issues of animal organs or growth of human tissue in vitro. Just as restenosis has spawned new research into latrogenic disease, so will every new treatment require investigation and treatment of its unintended consequences.
Our physicians will return to more cognitive pursuits as preventive strategies increase. In the short-to-medium term, however, there will be a need for the clinical molecular biologist (perhaps cum-interventionalist) who will translate the new knowledge and apply it more rapidly than ever before. Our physicians will return to their traditional role as patient advocate; the preoccupation with cost will diminish. Cost will be only one parameter: only those diagnostic and therapeutic regimens that significantly improve patient care at a reasonable cost will survive.
Our health care system will change. The Baby Boom generation is rapidly approaching the time when illness will visit them. This influx of an aging population will increase the overall cost of health care. Also, perhaps less obviously, the need for performance improvement and improved quality will lead to an increase in the cost of care. Americans, when presented with quality data that they understand, will choose the best health care available. This need for quality will cause a return to a more appropriate balance of specialty care than has been espoused in the past few years. The development of new technology, including molecular diagnostics and therapeutics, will improve the quality of life but will be expensive in both its development and practice. New technology will prolong life but will still require some degree of health care services. This increase in cost will not be borne easily by the current private payers for health care and is likely to result in less coverage and more disenfranchisement of greater segments of the population. Traditionally, the U.S. has provided health care coverage for those least able to pay, beginning with the elderly and the disabled and extending to the poor. In the future, it will be the middle class who will be disenfranchised. The ultimate solution will require health care coverage for all Americans.
One future prediction is certain: the ACC will continue to be the most relevant provider of medical education, performance improvement, and advocacy for those concerned with cardiovascular disease. If even a few of the changes I have outlined come to fruition, the knowledge deficit will deepen, and the role of the cardiovascular specialist in helping to shape the health care system will become even more pronounced. The ACC will be the agent for the practitioner in these areas. The College, building on its current and future membership, will be even stronger after its second 50 years than it is even after its amazing first 50 years.(1)
- American College of Cardiology
- ↵American College of Cardiology: A Visual History, 1949–1999. Bethesda, MD: American College of Cardiology, 1998.